About DWC

Medical Unit - Knee problems

Introduction

Management of knee problems in injured workers includes consideration of environmental and personal factors which may be causing or aggravating the problem, as well as providing treatment that leads to a return to productive work.

Scope of the guideline: This guideline deals with the assessment and treatment of knee problems, including 1) articular surface damage 2) bone damage 3) synovial and capsular damage 4) ligament injuries 5) patellofemoral tracking (chondromalacia) 6) meniscal injuries and 7) loose bodies in the knee. Knee problems can be acute (less than four weeks), subacute (one to three months), or chronic (greater than 3 months).

Initial assessment to rule out serious knee problems is discussed, but definite diagnosis and treatment of serious disorders is beyond the scope of this guideline. This guideline does not deal with issues of legal causation or work-relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted parameters for the assessment and treatment of knee injuries. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.

For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.

All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with the official medical fee schedule.

A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.

Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.

In all cases, the provider shall document no later than six months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having reached maximum medical improvement (i.e. permanent and stationary status).

1.0 Initial assessment

1.1 Purpose

The purpose of the initial assessment is to define the structural abnormality, in particular knee stability and intra articular abnormalities. Initial evaluation of an acute knee injury focuses on avoiding missed diagnoses. Early diagnoses of repairable abnormalities will speed return to work.

1.2 Appropriate initial assessment methods

1.2.1 History and physical

The history focuses on defining the nature of the injury, the duration of the knee complaint, and the past history of effusion. A history of previous knee injuries or other workplace injuries is important. Pain in the knee may be from the hip, the back, the thigh or the lower leg.

Clinical diagnosis of knee problems can usually be made on history and physical examination with the help of x-rays.

The presence of hemarthrosis suggests a more serious injury. Aspiration of a tense knee effusion may reduce pain and allow a more appropriate evaluation on physical examination. Injection of a local anesthetic may also be indicated.

The usual complaint of individuals with ligament insufficiencies is 'giving away'. Definition of the problem by physical examination is the first step in appropriate care. Appropriate tests should be used to identify ligamentous incompetence, disruption of a meniscus, articular surface irregularity and other soft tissue injury. Many injuries such as meniscus and ligament damage can be established by physical examination and may not require further tests.

Management during the first four weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every one to two weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary. If symptoms continue to increase despite adequate conservative therapy, or if there is significant disability due to pain, referral to a provider trained and experienced in the evaluation and treatment of occupational disorders is warranted in the initial treatment phase. Once the acute pain is controlled, the treatment should focus on progressive rehabilitative exercises to increase strength and endurance, and activity modification. This approach minimizes the chance of recurrence once normal occupational duties are resumed.

3.0 Secondary assessment

3.1 Purpose

The purpose of reassessment is to determine the reason for delayed recovery in patients who have not functionally improved. It is often difficult initially to assess the severity of the damage and/or instability. Therefore, reassess any individual who remains symptomatic after a trial of rehabilitation.

Appropriate tests may be performed with initiation of the rehabilitation process and particularly post operatively and may be necessary to be repeated upon conclusion of rehabilitation. (M=4) (C=) [ 3 ]

Special equipment which isolates the knee and measures strength may be helpful.

4.2.2.2 Reconstruction of ligaments is best done after appropriate rehabilitation to restore range of motion. (M=) (C=4) [ 4 ]

4.3 Inappropriate secondary treatments

4.3.1 Surgery

4.3.1.1 Total removal of the meniscus(M=1)(C=) [1]

The meniscus is an important component of knee mechanism. Even a mild degenerative meniscus is more useful than an absent meniscus. Excision of the total meniscus leads to a significant amount of problems. The modern approach is to remove as little as possible and try for repair in the younger individual.

4.3.1.2 Multiple ligament repairs performed at the same time as repairs to the meniscus (M=1) [ 1]

Multiple ligament repairs performed at the same time meniscus repairs may lead to a stiff joint.

4.3.3 Multiple steroid injections into the knee joint (greater than three), or into the ligament or tendon is rarely indicated. Direct steroid injections in the ligament or tendons of the knee is rarely indicated. Steroid injections of the bursae of the knee may be indicated. (M=1) (C=) [ 1 ]

4.3.4 Routine prescription of pain or sedative medication is not recommended and when prescribed for severe pain, should be limited in duration and quantity. (M=1) (C=) [ 1 ]

4.4 Case management

If the injured worker has not resumed near normal work duties after eight weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an orthopedic surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be rated for permanent disability. If psychosocial issues are judged to contribute delayed recovery heightened disability, it may be appropriate to have a psychiatric evaluation.

5.0 Prevention

5.1 Purpose

The purpose of preventive measures is to avoid reoccurrence of the knee problems.